ADHS-DBHS BEHAVIORAL HEALTH CLIENT COVER SHEET Address ________________________________________________
ADHS-DBHS BEHAVIORAL HEALTH CLIENT COVER SHEET Name__________________________________ DOB____________ Client CIS ID#____________________ Address ________________________________________________ Client SS#_____________________ City_______________ State______ Zip _____________ AHCCCS ID#_____________________ Phone_______________ E-Mail_______________________ AHCCCS Health Plan_____________________ Gender: Male Female Primary/Preferred Language_____________________ Special Needs: Interpreter Mobility Assistance Visual Impairment Assistance Hearing Impairment Assistance Need Childcare Arrangements No No No No No Yes, specify language_______________________________________________ Yes, identify assistance needed_______________________________________ Yes, identify assistance needed_______________________________________ Yes, identify assistance needed_______________________________________ Yes, identify need__________________________________________________ Key Contacts: PCP/Physician: _____________________________________ Phone______________ Fax______________ PCP/Physician Address: ___________________________________________________________________ Legal Guardian: ______________________________________________ Phone_________________ Custody: Sole Joint Ward of Court (DES Legal Guardian)__________________________ Parent(s)/Step Parent(s) _____________________________________________ Phone_________________ _____________________________________________ Phone_________________ _____________________________________________ Phone_________________ Emergency Contact: ________________________________________________ Phone_________________ Address_________________________________________________________________________________ Other Key Contacts (e.g., school, probation/parole officer, other involved agencies (CPS, DDD), neighbors, grandparents): Name and Relationship to Person ____________________________________________________________ Phone_______________ Fax_______________ Name and Relationship to Person ____________________________________________________________ Phone_______________ Fax_______________ Name and Relationship to Person ____________________________________________________________ Phone_______________ Fax_______________ Name and Relationship to Person ____________________________________________________________ Phone_______________ Fax_______________ Insurance Coverage: Medicare Private (self-pay) TriCare Insurance Co_______________________ (Attach copy of insurance card) Blue Cross HMO Other None Insurance ID #:__________ Policy No:______________ ---------------------------------------------------------------------------------------------------------------------------------------------------------------- Individual Completing Form and Title:___________________________________________ Date___________ ADHS/DBHS: 01/01/06 Version 1.0 1 ADHS-DBHS BEHAVIORAL HEALTH ASSESSMENT: BIRTH – 5 AND SERVICE PLAN CHECKLIST Name___________________________________________________ Date of Birth_____________ Client CIS ID#______________ Accompanying Parent/Caregiver (note relationship to child):___________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------------------------------------ Part A: Core Assessment (must be completed at this initial interview) Reason for Assessment Child’s Routines/Activities Developmental Issues Child’s Medical History Risk Assessment Pages 3 - 16 Family Information Observations and Reported Observations of the Child Observations of the Family-Child Interaction Clinical Formulation and Diagnoses Next Steps/Interim Service Plan Part B: Addenda (may be completed at subsequent appointment) Pages 17 - 42 Indicate below, which of the addenda you as the assessor have completed on the child during this interview Not Applicable To Be Completed Later Family Culture and History Biological and Adoptive Families Family Culture and History Foster Families ------- Developmental Checklist (or Ages and Stages Questionnaire) by age of child. (For all children, but if developmental issues are indicated at initial interview must be completed as part of Core Assessment.) Behavioral Analysis (For children in which primary need identified is a behavioral issue(s).) Medical Care (For children who have been hospitalized, resided outside of home for medical reasons or have been treated for seizures.) ------- Child Protective Services (Used for 24-hour urgent response for children removed by Child Protective Services.) Yes Name of Addendum Part C: Behavioral Health Service Plan (may be completed at subsequent appointment) Completed at initial interview Page 43 Will be completed later Part D: Annual Update and Review Summary Pages 44 - 47 _________________________________________________________ Assessor’s Name (print) / Signature _____________________ Credentials/Position ______________ Date __________________________________________________________ Behavioral Health Professional Reviewer Name (print) / Signature ______________________ Credentials/Position ______________ Date ______________________________________________________ Agency ADHS/DBHS: 01/01/06 Version 1.0 2 PART A: CORE ASSESSMENT: BIRTH – 5 Name:_____________________________________ PART A: CORE ASSESSMENT: BIRTH – 5 (For children from birth until the day they turn 5) REASON FOR ASSESSMENT 1. What concerns, needs or questions do you have regarding your child? What encouraged you to come in at this point in time? (Ask the parent/caregiver to describe the frequency, intensity and duration of symptoms, the circumstances in which they develop and continue to occur, the circumstances that improve or worsen them, etc.). __________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. What effect have these difficulties had on your family? What effect have these difficulties had on others who are involved with your child or family?_______________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. What have you already tried that has helped, not made a difference, or made it worse?___________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. Has your child received any previous evaluations or behavioral health services? Is your child currently receiving services from any other social service agency?______________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. What is the most important thing that we can do for you today?_____________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 6. What outcomes would you like to see occur from the services we will provide?_________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 3 PART A: CORE ASSESSMENT: BIRTH – 5 Name:_____________________________________ CHILD’S ROUTINES/ACTIVITIES 1. How well does your child fall asleep, stay asleep, or wake up in the morning?__________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. How well does your child eat? (Any difficulties or sensitivities to certain foods or food characteristics such as texture, smell, temperature? Any dietary restrictions? Any feeding or nursing problems with newborns? ) _______________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. How well does your child adapt to new situations or changes in routines? How well does your child respond to your attempts to soothe or console him/her when something upsets him/her?________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. How does your child react to everyday experiences such as being bathed, having hair washed, wearing new clothes, being swung or lifted in the air, hearing loud sounds or being in noisy situations, seeing vivid colors or bright lights? (Does your child seem overly sensitive to any of these? Does your child seem to not respond to things that you would expect him/her to?)____________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. Describe your child’s typical day._____________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ DEVELOPMENTAL ISSUES 1. What do you consider most unique or special about your child. What do you most appreciate, enjoy or take pride in about your child? What talents, gifts or strengths do you believe your child displays? ____________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 4 PART A: CORE ASSESSMENT: BIRTH – 5 Name:_____________________________________ DEVELOPMENTAL ISSUES (con’t) 2. Are there things your child learns more quickly than other children of the same age or can do physically that others cannot? No Yes, if yes explain. __________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Are there things your child learns more slowly than other children of the same age or cannot do physically that others can? No Yes, if yes explain. ______________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. 4. Do you have concerns about your child’s body control (e.g., toilet training, sitting up, taking first steps, using words, feeding self)? No Yes, if yes explain. __________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. Do you have concerns that your child may not be growing at a normal pace? No Yes, if yes explain __________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 6. Is your child unable to keep up with other children the same age when they play together? No Yes, if yes explain.______ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 7. Has your child ever been referred to, or received services through, the Division of Developmental Disabilities (DDD), Arizona Early Intervention Program (AzEIP) or Healthy Families or had an Individualized Education Plan (IEP)? No Yes, if yes explain. _________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Complete the Developmental Checklist or ASQ Addendum NOW if the responses to questions 3, 4, 5, 6 or 7 are YES. If not, the Addendum can be completed at a follow up appointment. ADHS/DBHS: 01/01/06 Version 1.0 5 PART A: CORE ASSESSMENT: BIRTH – 5 Name:_____________________________________ CHILD’S MEDICAL HISTORY 1. How is your child’s overall health today? (Do you consider him/her healthy?) _________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Does your child have any medical problems? Has he/she had any in the past? No Yes, if yes explain. Has your child had regular medical care? Yes No, if no explain. _____________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. 3. Does your child have any allergies to medicines, foods or other things in the environment (dust, pets, certain plants or pollens, etc.)? No Yes, if yes explain. __________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. Has your child had any head injuries or other injuries or illnesses that required a visit to a doctor, urgent care center or emergency room? No Yes, if yes explain. _________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Does your child take any prescription medication? No Yes, if yes explain. Any natural, herbal or alternative medicines or supplements? No Yes, if yes explain. Has your child required long term medications for any reason in the past? No Yes, if yes describe.__________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. Has your child ever been hospitalized, or needed to reside outside the home to receive medical care? No Yes, if yes explain __________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 6. 7. Has your child been treated for seizures? No Yes, if yes explain. _____________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Complete the Medical Addendum if the response to questions 6 or 7 is Yes. ADHS/DBHS: 01/01/06 Version 1.0 6 PART A: CORE ASSESSMENT: BIRTH – 5 Name:_____________________________________ RISK ASSESSMENT Has your child ever been hurt physically, emotionally or sexually? Has your child ever been abused? No Yes, if yes explain. Is your child currently in danger? No Yes, if yes explain.____________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 1. Has your child experienced neglect or deprivation of proper care-giving for any significant period? No Yes, if yes explain. Do you have any current concerns that your child is not well cared for? No Yes, if yes explain. ______________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. Has your child ever struck or intentionally harmed you or anyone else? No Yes, if yes explain. Do you or others feel unsafe around your child? No Yes, if yes explain.__________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. Have you ever harmed your child, felt close to harming your child or been accused of harming your child? No Yes, if yes explain. _________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. 5. Has your child ever sexually acted out? No Yes, if yes explain. _______________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 6. Has your child ever witnessed violence between other people? No Yes, if yes explain. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ONLY complete the questions below, if the response is Yes to one or more of the above questions. 7. How do you believe the issues above have affected you and your child? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 8. Do you believe any of these issues should be a focus of treatment at this time? No Yes, if yes explain. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 7 PART A: CORE ASSESSMENT: BIRTH – 5 Name:_____________________________________ RISK ASSESSMENT 9. Based on the responses above and your own observation, do you as the assessor believe: a. There is an immediate safety risk for the child or for any others close to the child? No Yes, if yes explain. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ b. The parent/caregiver appears to be at risk or has indications of the need for a crisis evaluation (observable symptoms, risk for withdrawal, malodorous, malnourished, dehydrated, etc)? No Yes, if yes explain. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Duty to Report: If you as the assessor believe that the child is or has been the victim of non-accidental physical injury, abuse, sexual abuse or deprivation, there is a duty to report to a peace officer or CPS (See A.R.S. 36-2881). If you are unclear about your duty to report, please consult with your supervisor. If duty to report is warranted, explain the action taken. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ FAMILY INFORMATION 1. Who lives at home all the time? Some of the time? Who else in the family lives nearby? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. Who provides care for your child and who else is important as a source of support or an important influence on your child (include grandparents, extended family, day care providers, teachers, physicians, ministers/pastors or other persons providing spiritual support)? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. Are there any current family stressors or situations that are affecting family functioning? No Yes, if yes explain. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 8 PART A: CORE ASSESSMENT: BIRTH – 5 Name:_____________________________________ OBSERVATIONS AND REPORTED OBSERVATIONS OF THE CHILD Based on his/her observations and impressions of the child, the assessor should describe the child’s: 1. Appearance. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. General presentation: a. 0-3 years of age (calm or fussy; clingy or detached; agitated or at ease; easy to soothe or hard to soothe; under reactive or over reactive to stimuli; content or crying; regressed or mature for age) or ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ b. 4-5 years of age (involved or detached; relaxed or anxious; playful or resistant to engaging; fearful or confident; labile or consistent). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. Initial reaction to changes during the assessment process (presence of strangers, changes in activity, brief separations and reunions with parents/caregiver). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. Ability to self regulate (reactions to external stimuli, atypical behaviors or movements, frustration tolerance). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. Speech (quality and quantity, age appropriateness of speech or vocalizations, volume, rate). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 9 PART A: CORE ASSESSMENT: BIRTH – 5 Name:_____________________________________ OBSERVATIONS AND REPORTED OBSERVATIONS OF THE CHILD (con’t) 6. Motor activity and coordination: a. Muscle tone and mobility: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ b. Gross coordination (infants: ability to push him/herself up, control head, sit or stand; toddlers: ability to walk, run, jump, hop, catch) ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ c. Fine motor coordination (infants: ability to grasp, throw, transfer from one hand to the other; toddlers: use of scissors, scribbling, catching) ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ d. Quality and quantity of activity (hyperactive, fidgety, restless, agitated, slowed) ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 7. Thoughts (fears, dreams or nightmares, preoccupations, disconnectedness, hallucinations). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 8. Mood and affect (verbal and nonverbal communication; facial expression; range, intensity and duration of expressed emotion; responsiveness to situations, parents/caregivers). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 9. Relatedness (to parents, to other family members, to examiner; describe level of physical contact, verbal and nonverbal expressions of affection). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 10. Play (level of sophistication, themes, level of initiation with family members or clinician, responsiveness to the initiation of play by others). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 11. Level of consciousness (alert, sedate, asleep). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 10 PART A: CORE ASSESSMENT: BIRTH – 5 Name:_____________________________________ OBSERVATIONS OF FAMILY-CHILD INTERACTIONS Based on his/her observations and impressions of the family-child interaction, the assessor should describe: 1. How the family plays together. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. The child’s interactions with siblings. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. The parents’/caregivers’ level of affection for their child. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. The parents’/caregivers’ willingness to engage and interact with their child. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. The appropriateness of the parents’/caregivers’ response to their child’s cues. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 6. The parents’/caregivers’ abilities to set limits for their child and to discipline. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 11 PART A: CORE ASSESSMENT: BIRTH – 5 Name:_____________________________________ OBSERVATIONS OF FAMILY-CHILD INTERACTIONS (con’t) 7. The parents’/caregivers’ ability to respond to and regulate their child’s emotional responses (are they able to soothe?). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 8. The parents’/caregivers’ level of vigilance and protectiveness of their child ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 9. The quality of the parents’/caregivers’ presentation of their child (How much do the parents/caregivers know about their child? What is their general attitude towards their child? What is their general attitude towards the assessor? How do they talk about their child?). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 12 PART A: CORE ASSESSMENT: BIRTH – 5 Name:_____________________________________ CLINICAL FORMULATION AND DIAGNOSES A. Clinical Formulation/Case Summary: In a succinct paragraph, the assessor should: Provide a descriptive picture of the child and family by summarizing pertinent data from the child and family’s history, the observations of the child, and the observations of the family-child interaction. Summarize how biopsychosocial, cultural, environmental and family factors have impacted the child and family’s history and current condition. Consider how issues such as parental neglect or abuse, inconsistent availability of primary caregivers, or environmental situations that interfered with appropriate care giving have impacted stable attachments. Identify the strengths and needs of the child and family. Prioritize the needs to be addressed in a manner that allows the family to readily understand what needs to be done next. If the primary needs identified thus far are related to the child’s behavior, the Behavioral Analysis Addendum should be completed but this can occur at a follow-up appointment. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ B. Diagnostic Summary: 1. Axis I _____________ ___________________________________ _____________ ___________________________________ DSM-IV TR Code DSM-IV TR Code DSM-IV Diagnosis DSM-IV Diagnosis ______________ ___________________________________ ______________ ___________________________________ DSM-IV TR Code DSM-IV TR Code DSM-IV Diagnosis DSM-IV Diagnosis ______________ ___________________________________ DSM-IV TR Code DSM-IV Diagnosis 2. Axis II _____________ ___________________________________ _____________ ___________________________________ DSM-IV TR Code DSM-IV TR Code DSM-IV Diagnosis ADHS/DBHS: 01/01/06 Version 1.0 DSM-IV Diagnosis 13 PART A: CORE ASSESSMENT: BIRTH – 5 Name:_____________________________________ CLINICAL FORMULATION AND DIAGNOSES (con’t) 3. Axis III - Medical Conditions: Identify the person’s specific medical conditions and check the disease categories below that apply. Infectious and Parasitic Diseases (001-139): abscesses, infections, tuberculosis, HIV/AIDS, pneumonia, blood infections, CMV, RSV Neoplasms (140-239): cancer Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders (240-279): diabetes, thyroid disorders, iron or vitamin deficiencies, immune deficiencies Diseases of the Blood and Blood-Forming Organs (280-289): hemophilia, anemia Diseases of the Nervous System and Sense Organs (320-389): blindness, deafness, loss of sensation, hypoxic encephalopathy, intraventricular hemorrhage, meningitis, hydrocephalus, seizures Diseases of the Circulatory System (390-459): congenital heart defect, cardiomyopathy Diseases of the Respiratory System (460-519): asthma, chronic lung disease, tracheomalacia Diseases of the Digestive System (520-579): stomach disorders, ulcers, esophageal reflux (GERD), liver disease, pancreatic disease, pediatric under-nutrition, anomalies, feeding difficulties Diseases of the Genitourinary System (580-629): bladder problems, kidney (renal) disorders or anomalies Complications of Pregnancy, Childbirth, and the Puerperium (630-676): prematurity, intrauterine growth retardation, intrauterine drug or alcohol exposure, fetal alcohol syndrome Diseases of the Skin and Subcutaneous Tissue (680-709) Diseases of the Musculoskeletal System and Connective Tissue (710-739): orthopedic disorders, fractures/dislocations /deformities, cerebral palsy Congenital Anomalies (740-759): genetic disorders, birth deformities Certain Conditions Originating in the Perinatal Period (760-779): failure to thrive, colic, feeding problems Symptoms, Signs, and Ill-Defined Conditions (780-799): retinopathy or prematurity, rickets, chronic otitis media (ear infections) Injury and Poisoning (800-999): traumatic injuries, ingestions of poisonous/toxic substances 4. Axis IV - Psychosocial or Environmental Stressors Problems with / related to: Primary Support Group Educational Problems Occupational Problems Marital Problems Housing Problems Interaction with Legal System Access to Health Care Services Family Problems Substance Use in Home Other______________________________________________________________________ Significant recent losses: Death Injury Medical/Surgical Job Divorce/Separation Accident/Injury Child removed from home Violent Acts Against Person/Family Other_______________________________________________________________________ 5. Axis V –Children’s Global Assessment Scale (CGAS) Score (specific score not a range): ______________** Scale 100-91 90-81 80-71 70-61 60-51 50-41 40-31 30-21 20-11 10-1 ADHS/DBHS: 01/01/06 Version 1.0 Children’s Global Assessment Scale (CGAS) Children Superior Functioning Good Functioning in All Areas No More Than Slight Impairment in Functioning Some Difficulty in A Single Area, But Generally Functioning Pretty Well Variable Functioning with Sporadic Difficulties or Symptoms in Several but Not All Social Areas Moderate Degree of Interference in Functioning in Most Social Areas or Severe Impairment of Functioning in One Area Major Impairment in Functioning in Several Areas and Unable to Function in One of These Areas Unable to Function in Almost All Areas Needs Considerable Supervision (above and beyond that which is age appropriate) Needs Constant Supervision (above and beyond that which is age appropriate) 14 PART A: CORE ASSESSMENT: BIRTH – 5 Name:_____________________________________ NEXT STEPS/INTERIM SERVICE PLAN 1. Interim Service Plan. Based on the child’s presenting issues, your impressions and the preferences of the child and his/her parents/caregivers, describe in the Interim Service Plan below recommended next steps (e.g., formation of a Team*, response to immediate risks and needs of the child, further assessment, appropriate referrals). Additionally, this Interim Service Plan should include: Referral to the child’s primary care physician, if physical health problems have been identified or if the child has not had regular well-child EPSDT visits. Referral of any child under the age of 3 to AzEIP, if triggered by the Developmental Checklist Addendum. Additional considerations for urgent response for children removed by Child Protective Services** The assessor may also add a goal statement, if appropriate. *If an AzEIP IFSP team has been formed for the child, the Clinical Liaison will coordinate CFT functions with IFSP functions so as to avoid duplicative processes between systems and to ensure consistency and compatibility of service plans. **For urgent response for children removed by Child Protective Services, the assessor must include as part of the recommended next steps/interim service plan, identification of: 1. Actions needed to be taken immediately to mitigate the effects of the removal itself; 2. Supports and services the child’s caregivers may need to meet the child’s needs; and 3. A plan to ensure that even asymptomatic children are reassessed and observed for surfacing behavioral health needs within at least the next 23 days (or sooner if indicated). The assessor may also provide any input he/she has regarding the types and amount/frequency of contact (e.g., visits, phone calls, e-mail), the child should have with parents, siblings, relatives and other individuals important to the child. Description of Next Steps (Action) to Be Taken ADHS/DBHS: 01/01/06 Version 1.0 Who Will Be Responsible to Ensure Action Occurs Where Action/Step Will Take Place (e.g., provider) When Action/ Step Will Take Place 15 PART A: CORE ASSESSMENT: BIRTH – 5 Name:_____________________________________ NEXT STEPS/INTERIM SERVICE PLAN (con’t) 2. Identify any immediate next steps to be taken by the parent/caregiver (including how these next steps will be accomplished and where and when these steps will be taken): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. Identify specific people who may be supportive and helpful and who should be invited to be part of the child’s Child and Family Team (or AzEIP Team), including phone numbers and action to be taken: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. Identify any additional documentation (e.g., medical records, IEP), which needs to be collected to assist in the ongoing assessment and service planning including the individuals and/or agencies and action to be taken to obtain this information: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. Identify who the parent/caregiver should contact if their child needs immediate assistance before the next appointment: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------------------------------------ __________________________________________________________ Parent/Caregiver Signature/Guardian __________________ Date _________________________________________________________ Assessor’s Name (print) / Signature _____________________ Credentials/Position ______________ Date __________________________________________________________ Behavioral Health Professional Reviewer Name (print) / Signature ______________________ Credentials/Position ______________ Date ______________________________________________________ Agency Note: The assessor should make sure to provide the parent/caregiver with a copy of the interim service plan. The CPS specialist, however, should receive a copy of the entire next steps/ interim service plan section. ADHS/DBHS: 01/01/06 Version 1.0 16 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ PART B: ADDITIONAL ADDENDA: BIRTH – 5 FAMILY CULTURE AND HISTORY If addendum completed at follow-up appointment, assessor should sign __________________________________ and date _______________ (BIOLOGICAL AND ADOPTIVE FAMILIES) 1. What are the things that make your family members feel good about themselves and help make your lives meaningful (include interests, strengths, talents, skills and abilities, knowledge/education, friends, extended family, values, religion/spirituality, culture/community, work, school, etc.)? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. Is there anything that your family describes about itself or its cultural background that would help the assessor understand you better or how people respond to you? How does your cultural background influence you or the people who are most important to you? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. Describe your family’s support system (the individuals with whom you are most comfortable, to whom do you turn for help, with whom do you feel most comfortable when talking about important matters?). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. Who in the family does your child remind you of the most, and what is each parent’s response to that person? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Has your child ever experienced any situations where he/she had multiple or inconsistent caregivers? No Yes, if yes explain. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. 6. Have you used the services of any daycare? No Yes Has your child been in a nursery or pre-school? No Yes ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 17 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ FAMILY CULTURE AND HISTORY (BIOLOGICAL AND ADOPTIVE FAMILIES) (con’t) 7. Has your child ever lived outside the home (with relatives, CPS, temporary guardian, crisis nursery, shelter etc.)? No Yes, if yes for each out of home experience, describe the following: (If the child resided outside of the home due to medical needs, please complete the Medical Care Addendum.) The timeframe your child was out of home. Where your child lived. The reason your child was out of home. Who decided your child needed to be placed out of home Any behavioral, developmental or health changes noticed upon your child’s return to home. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 8. Were there any complications during the pregnancy, at the time of birth, or in the first year after the delivery for either mother or baby (including mother’s injuries, use of drugs/alcohol during the pregnancy or extended hospital stay for mother or baby)? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 9. Describe the important events in the personal history of each parent (e.g., deaths, separations from a parent or sibling, their parent’s separation or divorce, physical or sexual abuse or exposure to violence). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 10. Describe each parent’s experience of being raised in his/her own family (who raised them, who had the most influence, who is their positive and negative model for how to parent their own child?). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 18 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ FAMILY CULTURE AND HISTORY (BIOLOGICAL AND ADOPTIVE FAMILIES) (con’t) 11. Describe the medical and mental health/substance abuse history of each parent, including current and past problems, evaluations or services. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 12. Describe the history of the parents’ relationship with each other (how long have they known each other, how well do they get along, have there been any separations or divorce)? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 13. Any history of arrests or current legal involvement? No Yes, if yes explain. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 14. Describe the medical and mental health/substance abuse history of grandparents, including current and past problems, evaluations or services. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 15. Any history of arrests or current legal involvement in grandparents’ history? No Yes, if yes explain. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ For Biological Families only: 16. What effect did the pregnancy have on each parent, their relationship with each other and with other family members? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 19 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ FAMILY CULTURE AND HISTORY (BIOLOGICAL AND ADOPTIVE FAMILIES) (con’t) 17. Did the pregnancy create any additional stresses on either parent or other family members? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 18. What changed for each parent when they became aware of the pregnancy (e.g., work, schedule, lifestyle, attitudes)? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ For Adoptive Families only: 19. What do you know about the pregnancy, delivery, and early life experiences of the child? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 20. Does the child remember the biological parents/family? Does the child ask for or inquire about them? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 20 PART B: ADDENDA: BIRTH – 5 FAMILY CULTURE AND HISTORY Name:_____________________________________ If addendum completed at follow-up appointment, assessor should sign __________________________________ and date _______________ (FOSTER FAMILIES) 1. What are the things that make your family members feel good about themselves and help make your lives meaningful (include interests, strengths, talents, skills and abilities, knowledge/education, friends, extended family, values, religion/spirituality, culture/community, work, school, etc.)? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. Is there anything that your family describes about itself or its cultural background that would help the assessor understand you better or how people respond to you? How does your cultural background influence you or the people who are most important to you? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. Describe your family’s support system (the individuals with whom you are most comfortable, to whom do you turn for help, with whom do you feel most comfortable when talking about important matters?). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Has your child ever experienced any situations where he/she had multiple or inconsistent caregivers? No Yes, if yes explain. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. 5. Have you used the services of any daycare? No Yes Has the child been in a nursery or pre-school? No Yes ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 6. How long has the child been in your home? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 7. How many previous placements have there been and what for what lengths of time? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 8. How have the relationships between your family and the child developed? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 9. What was the child like when he/she first arrived? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 10. How would you describe the child now? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 21 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ FAMILY CULTURE AND HISTORY (FOSTER FAMILIES) (con;t) 11. What effect did the child’s entry into your home have on others in the family? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 12. What do you know about the pregnancy, delivery, and early life experiences of the child? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 13. Does the child remember the biological parents/family? Does the child ask for or inquire about them? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 14. Describe the important events in the personal history of each foster parent (e.g., deaths, separations from a parent or sibling, their parent’s separation or divorce, physical or sexual abuse or exposure to violence). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 15. Describe each foster parent’s experience of being raised in his/her own family (who raised them, who had the most influence, who is their positive and negative model for how to parent their own child?). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 22 PART B: ADDENDA: BIRTH – 5 DEVELOPMENTAL CHECKLIST Name:_____________________________________ 2 If addendum completed at follow-up appointment, assessor should sign __________________________________ and date _______________ (Must be completed at initial visit if developmental concerns are identified on the Developmental Issues Section) The Ages and Stages Questionnaire may be used as an alternative to the Developmental Checklist. I. ONE TO THREE MONTHS A. Developmental Checklist Movement Yes No Raises head and cheek when lying on stomach (3 mos.) Supports upper body with arms when lying on stomach (3 mos.) Stretches legs out when lying on stomach or back (2-3 mos.) Opens and shuts hands (2-3 mos.) Pushes down on his legs when feet are placed on firm surface (3 mos.) Watches face intently (2-3 mos.) Follows moving objects (2 mos.) Recognizes familiar objects and people at a distance (3 mos.) Starts using hands and eyes in coordination (3 mos.) Smiles at the sound of voice (2-3 mos.) Cooing noises; vocal play begins at 3 mos. Attends to sound (1-3 mos.) Startles to loud noise (1-3 mos.) Begins to develop a social smile (1-3 mos.) Enjoys playing with other people and may cry when playing stops (2-3 mos.) Becomes more communicative and expressive with face and body (2-3 mos.) Imitates some movements and facial expressions Visual Hearing and Speech Social and Emotional 2 With permission of the authors, this checklist is based on a checklist adapted by First Look and The Early Childhood Direction Center from Shelov, S.P. & Hannenmann, R.E. (1994). The American Academy of Pediatrics: Caring for Your Baby and Young Child Birth to Age 5: The Complete and Authoritative Guide. New York: Bantam Doubleday Dell Pub. ADHS/DBHS: 01/01/06 Version 1.0 23 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ DEVELOPMENTAL CHECKLIST: 1-3 MONTHS. (con’t) B. Developmental Red Flags* Does not seem to respond to loud noises Does not follow moving objects with eyes by 2-3 mos. Does not smile at the sound of your voice by 2 mos. Does not grasp and hold objects by 3 mos. Does not smile at people by 3 mos. Cannot support head well at 3 mos. Does not reach for and grasp toys by 3-4 mos. Does not bring objects to mouth by 4 mos. Does not push down with legs when feet are placed on a firm surface by 4 mos. Has trouble moving one or both eyes in all directions Crosses eyes most of the time (occasional crossing of the eyes is normal in these first months) Comments: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ *Please note that any “Red Flags” identified should trigger a referral to the child’s PCP as well as a referral to AzEIP. ADHS/DBHS: 01/01/06 Version 1.0 24 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ If addendum completed at follow-up appointment, assessor should sign DEVELOPMENTAL CHECKLIST __________________________________ and date _______________ (Must be completed at initial visit if developmental concerns are identified on the Developmental Issues Section) The Ages and Stages Questionnaire may be used as an alternative to the Developmental Checklist. 3 II. FOUR TO SEVEN MONTHS A. Developmental Checklist Movement Yes No Pushes up on extended arms (5 mos.) Pulls to sitting with no head lag (5 mos.) Sits with support of hands (5-6 mos.) Sits unsupported for short periods (6-8 mos.) Supports his/her whole weight on legs (6-7 mos.) Grasps feet (6 mos.) Transfers objects from hand to hand (6-7 mos.) Uses raking grasp (not pincer) (6 mos.) Looks for toy beyond tracking range (5-6 mos.) Tracks moving objects with ease (4-7 mos.) Grasps objects dangling in front of him/her (5-6 mos.) Looks for fallen toys (5-7 mos.) Distinguishes emotions by tone of voice (4-7 mos.) Responds to sound by making sounds (4-6 mos.) Uses voice to express joy and displeasure (4-6 mos.) Syllable repetition begins (5-7 mos.) Finds partially hidden objects (6-7 mos.) Explores with hands and mouth (4-7 mos.) Struggles to get objects that are out of reach (5-7 mos.) Visual Language Cognitive 3 With permission of the authors, this checklist is based on a checklist adapted by First Look and The Early Childhood Direction Center from Shelov, S.P. & Hannenmann, R.E. (1994). The American Academy of Pediatrics: Caring for Your Baby and Young Child Birth to Age 5: The Complete and Authoritative Guide. New York: Bantam Doubleday Dell Pub. ADHS/DBHS: 01/01/06 Version 1.0 25 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ DEVELOPMENTAL CHECKLIST: 4-7 MONTHS. (con’t) Social Emotional Yes No Enjoys social play (4-7 mos.) Interested in mirror images (5-7 mos.) Responds to other people’s expression of emotion (4-7 mos.) B. Developmental Red Flags* Seems very stiff, tight muscles Seems very floppy, like a rag doll Head still flops back when body is pulled to sitting position (by 5 mos. still exhibits head lag) Shows no affection for the person who cares for him/her Does not seem to enjoy being around people One or both eyes consistently turn in or out Persistent tearing, eye drainage, or sensitivity to light Does not respond to sounds around him/her Has difficulty getting objects to mouth Does not turn head to locate sounds by 4 mos. Does not roll over (stomach to back) by 6 mos. Cannot sit with help by 6 mos. (not by themselves) Does not laugh or make squealing sounds by 5 mos. Does not actively reach for objects by 6 mos. Does not follow objects with both eyes Does not bear some weight on legs by 5 mos. Comments: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ *Please note that any “Red Flags” identified should trigger a referral to the child’s PCP as well as a referral to AzEIP. ADHS/DBHS: 01/01/06 Version 1.0 26 PART B: ADDENDA: BIRTH – 5 DEVELOPMENTAL CHECKLIST Name:_____________________________________ 4 If addendum completed at follow-up appointment, assessor should sign __________________________________ and date _______________ (Must be completed at initial visit if developmental concerns are identified on the Developmental Issues Section) The Ages and Stages Questionnaire may be used as an alternative to the Developmental Checklist. III. EIGHT TO TWELVE MONTHS A. Developmental Checklist Movement Yes No Gets to sitting position without assistance (8-10 mos.) Crawls forward on belly Assumes hand and knee position Creeps on hands and knees Gets from sitting to crawling or prone (lying on stomach) position (10-12 mos.) Pulls self up to standing position Walks holding onto furniture Stands momentarily without support May walk two or three steps without support Uses pincer grasp (7-10 mos.) Bangs two cubes together Puts objects into container (10-12 mos.) Takes objects out of container (10-12 mos.) Pokes with index finger Tries to imitate scribbling Explores objects in many different ways; shaking, banging, throwing, dropping (8-10 mos.) Finds hidden objects easily (10-12 mos.) Looks at correct picture when image is named Imitates gestures (9-12 mos.) Hand and Finger Skills Cognitive 4 With permission of the authors, this checklist is based on a checklist adapted by First Look and The Early Childhood Direction Center from Shelov, S.P. & Hannenmann, R.E. (1994). The American Academy of Pediatrics: Caring for Your Baby and Young Child Birth to Age 5: The Complete and Authoritative Guide. New York: Bantam Doubleday Dell Pub. ADHS/DBHS: 01/01/06 Version 1.0 27 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ DEVELOPMENTAL CHECKLIST: 8-12 MONTHS. (con’t) Language Yes No Responds to simple verbal requests Responds to “no” Makes simple gestures such as shaking head for no (8-12 mos.) Babbles with inflection (8-10 mos.) Babbles “dada” and “mama” (8-10 mos.) Babbles “dada” and “mama” for specific person (11-12 mos.) Uses exclamations such as “oh-oh” Shy or anxious with strangers (8-12 mos.) Cries when mother or father leaves (8-12 mos.) Enjoys imitating people in play (10-12 mos.) Shows specific preferences for certain people and toys (8-12 mos.) Prefers mother and/or regular care provider over all others (8-12 mos.) Repeats sounds or gestures for attention (10-12 mos.) Finger-feeds him/herself (8-12 mos.) Extends arm or leg to help when being dressed Social and Emotional Social and Emotional (continued) B. Developmental Red Flags* Does not crawl Drags one side of body while crawling (for over one month) Cannot stand when supported Does not search for objects that are hidden (10-12 mos.) Does not say single words (“mama” or “dada”) Does not learn to use gestures such as waving or shaking head Does not sit steadily by 10 mos. Does not show interest in “peek-a-boo” or “patty cake” by 8 mos. Does not babble by 8 mos. Does not babble by 8 mos. (“dada”, “baba”, “mama”) Comments: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ *Please note that any “Red Flags” identified should trigger a referral to the child’s PCP as well as a referral to AzEIP. ADHS/DBHS: 01/01/06 Version 1.0 28 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ If addendum completed at follow-up appointment, assessor should sign DEVELOPMENTAL CHECKLIST __________________________________ and date _______________ (Must be completed at initial visit if developmental concerns are identified on the Developmental Issues Section) The Ages and Stages Questionnaire may be used as an alternative to the Developmental Checklist. 5 IV. TWELVE TO TWENTY-FOUR MONTHS A. Developmental Checklist Movement Yes No Walks alone (12-16mos.) Pulls toys behind while walking (13-16 mos.) Carries large toy or several toys while walking (12-15 mos.) Begins to run stiffly (16-18 mos.) Walks into ball (18-24 mos.) Climbs onto and down from furniture unsupported (16-24 mos.) Walks up and down stairs holding on to support (18-24 mos.) Stands momentarily without support Scribbles spontaneously (14-16 mos.) Turns over container to pour out contents (12-18 mos.) Building tower of 4 blocks, or more (20-24 mos.) Points to object or picture when it’s named for him/her (18-24 mos.) Recognizes names or familiar people, objects, and body parts (18-24 mos.) Says several single words (15-18 mos.) Uses two word sentences (14-18 mos.) Follows simple one-step instructions (14-18 mos.) Repeats words overheard in conversations (16-18 mos.) Finds objects even when hidden under 2 or 3 covers Begins to sort shapes and colors (20-24 mos.) Hand and Finger Skills Language Cognitive 5 With permission of the authors, this checklist is based on a checklist adapted by First Look and The Early Childhood Direction Center from Shelov, S.P. & Hannenmann, R.E. (1994). The American Academy of Pediatrics: Caring for Your Baby and Young Child Birth to Age 5: The Complete and Authoritative Guide. New York: Bantam Doubleday Dell Pub. ADHS/DBHS: 01/01/06 Version 1.0 29 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ DEVELOPMENTAL CHECKLIST: 12-24 MONTHS. (con’t) Yes No Begins make-believe play (20-24 mos.) Imitates behavior of others, especially adults and older children (18-24 mos.) Increasingly enthusiastic about company of other children (20-24 mos.) Demonstrates increasing independence (18-24 mos.) Begins to show defiant behavior (18-24 mos.) Episodes of separation anxiety increase toward midyear, then fade Social and Emotional B. Developmental Red Flags* Cannot walk by 18 mos. Fails to develop a mature heel-toe walking pattern after several months of walking, or walks exclusively on his toes Does not speak at least 15 words by 18 mos. Does not use two word sentences by age 2 Does not seem to know the function of common household objects (brush, telephone, bell, fork, spoon) by 15 mos. Does not imitate actions or words by 24 mos. Does not follow simple one-step instructions by 24 mos. Comments: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ *Please note that any “Red Flags” identified should trigger a referral to the child’s PCP as well as a referral to AzEIP. ADHS/DBHS: 01/01/06 Version 1.0 30 PART B: ADDENDA: BIRTH – 5 DEVELOPMENTAL CHECKLIST Name:_____________________________________ 6 If addendum completed at follow-up appointment, assessor should sign __________________________________ and date _______________ (Must be completed at initial visit if developmental concerns are identified on the Developmental Issues Section) The Ages and Stages Questionnaire may be used as an alternative to the Developmental Checklist. V. TWENTY-FOUR TO THIRTY-SIX MONTHS A. Developmental Checklist Movement Yes No Climbs well (24-30 mos.) Walks down stairs alone, placing both feet on each step (26-28 mos.) Walks up stairs alternating feet with support (24-30 mos.) Swings leg to kick ball (24-30 mos.) Runs easily (24-26 mos.) Pedals tricycle (30-36 mos.) Bends over easily without falling (24-30 mos.) Makes vertical, horizontal, circular strokes with pencil or crayon (30-36 mos.) Turns book pages one at a time (24-30 mos.) Builds a tower of more than 6 blocks (24-30 mos.) Holds a pencil in writing position (30-36 mos.) Screws and unscrews jar lids, nuts and bolts (24-30 mos.) Turns rotating handles (24-30 mos.) Recognizes and identifies almost all common objects and pictures (26-32 mos.) Understands most sentences (24-40 mos.) Understands physical relationship, e.g., on, in, under (30-36 mos.) Can say name, age, and sex (30-36 mos.) Uses pronoun, e.g., you, me, we, they (24-30 mos.) Strangers can understand most of his/her words (30-36 mos.) Hand and Finger Skills Language 6 With permission of the authors, this checklist is based on a checklist adapted by First Look and The Early Childhood Direction Center from Shelov, S.P. & Hannenmann, R.E. (1994). The American Academy of Pediatrics: Caring for Your Baby and Young Child Birth to Age 5: The Complete and Authoritative Guide. New York: Bantam Doubleday Dell Pub. ADHS/DBHS: 01/01/06 Version 1.0 31 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ DEVELOPMENTAL CHECKLIST: 24-36 MONTHS. (con’t) Cognitive Yes No Makes mechanical toys work (30-36 mos.) Matches an object in hand or room to a picture in a book (24-30 mos.) Plays make believe with dolls, animals, and people (24-36 mos.) Sorts objects by color (30-36 mos.) Completes puzzles with 3 or 4 pieces (24-36 mos.) Understands concept of “two” (26-32 mos.) Separates easily from parents by three Expresses a wide range of emotions (24-36 mos.) Objects to major changes in routine (24-36 mos.) Social and Emotional B. Developmental Red Flags* Frequent falling and difficulty with stairs Persistent drooling or very unclear speech Inability to build a tower of more than 4 blocks Difficulty manipulating small objects Inability to copy a circle by 3 Inability to communicate in short phrases No involvement in pretend play Failure to understand simple instructions Little interest in other children Extreme difficulty separating from primary caregiver Comments: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ *Please note that any “Red Flags” identified should trigger a referral to the child’s PCP as well as a referral to AzEIP. ADHS/DBHS: 01/01/06 Version 1.0 32 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ If addendum completed at follow-up appointment, assessor should sign DEVELOPMENTAL CHECKLIST __________________________________ and date _______________ (Must be completed at initial visit if developmental concerns are identified on the Developmental Issues Section) The Ages and Stages Questionnaire may be used as an alternative to the Developmental Checklist. 7 VI. THREE TO FOUR YEARS A. Developmental Checklist Movement Yes No Hops and stands on one foot up to 5 seconds Goes upstairs and downstairs without support Kicks ball forward Throws ball overhand Catches bounced ball most of the time Moves forward and backward Uses riding toys Copies square shapes Draws a person with 2 to 4 body parts Uses scissors Draws circles and squares Begins to copy some capital letters Can feed self with spoon Understands the concepts of “same” and “different” Has mastered some basic rules of grammar Speaks in sentences of 5 to 6 words Asks questions Speaks clearly enough for strangers to understand Tells stories Hand and Finger Skills (by the end of age 3) Language (by the end of age 3) 7 With permission of the authors, this checklist is based on a checklist adapted by First Look and The Early Childhood Direction Center from Shelov, S.P. & Hannenmann, R.E. (1994). The American Academy of Pediatrics: Caring for Your Baby and Young Child Birth to Age 5: The Complete and Authoritative Guide. New York: Bantam Doubleday Dell Pub. ADHS/DBHS: 01/01/06 Version 1.0 33 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ DEVELOPMENTAL CHECKLIST: 3-4 YEARS. (con’t) Cognitive (by the end of age 3) Yes No Correctly names some colors Understands the concept of counting and may know a few numbers Begins to have a clearer sense of time Follows three-part commands Recalls parts of a story Understands the concept of same/different Engages in fantasy play Understands causality (“I can make things happen”) Interested in new experiences Cooperates/plays with other children Plays “mom” or “dad” More inventive in fantasy play Dresses and undresses More independent Often cannot distinguish between fantasy and reality May have imaginary friends or see monsters Social and Emotional (by the end of age 3) B. Developmental Red Flags* Cannot jump in place Cannot ride a trike Cannot grasp a crayon between thumb and fingers Has difficulty scribbling Cannot copy a circle Cannot stack four blocks Still clings or cries when parents leave him Shows no interest in interactive games Ignores other children Does not respond to people outside the family Does not engage in fantasy play Resists dressing, sleeping, using the toilet Lashes out without any self-control when angry or upset Does not use sentences of more than three words Does not use “me” or “you” appropriately Comments: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ *Please note that any “Red Flags” identified should trigger a referral to the child’s PCP and any symptoms that suggest likely difficulties learning should trigger a referral to the school for an evaluation. ADHS/DBHS: 01/01/06 Version 1.0 34 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ If addendum completed at follow-up appointment, assessor should sign DEVELOPMENTAL CHECKLIST __________________________________ and date _______________ (Must be completed at initial visit if developmental concerns are identified on the Developmental Issues Section) The Ages and Stages Questionnaire may be used as an alternative to the Developmental Checklist. 8 VII. FOUR TO FIVE YEARS A. Developmental Checklist Movement Yes No Stands on one foot for 10 seconds or longer Hops, somersaults Swings, climbs May be able to skip Copies triangle and other geometric patterns Draws person with body Prints some letters Dresses and undresses without assistance Uses fork, spoon Usually cares for own toilet needs Recalls parts of a story Speaks sentences of more than 5 words Uses future tense Tells longer stories Says name and address Can count 10 or more objects Correctly names at least 4 colors Better understands the concept of time Knows about things used every day in the home (money, food, etc.) Hand and Finger Skills (by the end of age 4) Language (by the end of age 4) Cognitive (by the end of age 4) 8 With permission of the authors, this checklist is based on a checklist adapted by First Look and The Early Childhood Direction Center from Shelov, S.P. & Hannenmann, R.E. (1994). The American Academy of Pediatrics: Caring for Your Baby and Young Child Birth to Age 5: The Complete and Authoritative Guide. New York: Bantam Doubleday Dell Pub. ADHS/DBHS: 01/01/06 Version 1.0 35 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ DEVELOPMENTAL CHECKLIST: 4-5 YEARS (con’t) Cognitive (continued) Yes No Wants to please and be with friends More likely to agree to rules Likes to sing, dance, and act Shows more independence B. Developmental Red Flags* Exhibits extremely aggressive, fearful or timid behavior Is unable to separate from parents Is easily distracted and unable to concentrate on any single activity for more than 5 minutes Shows little interest in playing with other children Refuses to respond to people in general Rarely uses fantasy or imitation in play Seems unhappy or sad much of the time Avoids or seems aloof with other children and adults Does not express a wide range of emotions Has trouble eating, sleeping or using the toilet Cannot differentiate between fantasy and reality Seems unusually passive Cannot understand two part commands and prepositions (“put the cup on the table”; “get the ball under the couch”) Cannot give first and last name Does not use plurals or past tense Cannot build a tower of 6 to 8 blocks Seems uncomfortable holding a crayon Has trouble taking off clothing Cannot brush teeth or wash and dry hands Comments: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ *Please note that any “Red Flags” identified should trigger a referral to the child’s PCP and any symptoms that suggest likely difficulties learning should trigger a referral to the school for an evaluation. ADHS/DBHS: 01/01/06 Version 1.0 36 PART B: ADDENDA: BIRTH – 5 BEHAVIORAL ANALYSIS Name:_____________________________________ If addendum completed at follow-up appointment, assessor should sign __________________________________ and date _______________ (For children in which primary need identified is related to the child’s behavior) A. Descriptive Analysis of the Child’s Behavior. 1. Describe the behavior of concern by general type (e.g., aggressive, self injurious, oppositional), then in specific terms (e.g., biting, refusing to eat, screaming). This should be listed as one of the needs and objectives in the Service Plan. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. When did the behavior first start? Were there any significant events or changes in your child’s life, family or routine about this same time? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. Describe the duration of the behavior (e.g., minutes, hours, days). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. Describe the frequency of the behavior (e.g., every hour, three times a day, once a week). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. Describe where the behavior occurs (e.g., everywhere, only at home, only in the car). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 6. Identify in whose presence the behavior occurs (e.g., everyone, only mother, anyone except grandmother). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 7. Does this behavior bother everyone involved with the child equally, or does it bother some more than others? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 8. Describe when the behavior occurs (e.g., all day, bedtime, when hungry, when left alone, when ill or fatigued). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 9. Describe any activities that are associated with the behavior (e.g., feeding child, arguing with someone, picking up child). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 10. What do you (or other parent/caregiver) usually do to prevent the behavior, and how effective is this? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 37 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ BEHAVIORAL ANALYSIS (con’t) 11. What is usually your (or other parent/caregiver) immediate reaction to the behavior? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 12. What do you (or other parent/caregiver) usually do as a consequence to the behavior, and how effective is this? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 13. Is the behavior worse, better or different if routines are followed or disrupted? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ B. Need/Intention Analysis 1. What do you believe is the reason for the behavior or the cause of the behavior? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. Describe any additional or different possible needs or intentions behind the behavior that you as the assessor see. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. If certain needs or intentions are believed to be driving the behavior, describe how often and how well you believe these needs are being met? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. How do you believe that these needs or intentions should be handled given your preferences, cultural background, beliefs, etc.? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 38 PART B: ADDENDA: BIRTH – 5 MEDICAL CARE Name:_____________________________________ If addendum completed at follow-up appointment, assessor should sign __________________________________ and date _______________ (For children, who have been hospitalized, resided outside of home for medical reasons or have been treated for seizures) A. If your child has a history of seizures, answer the following questions: 1. What kind of seizures has your child had? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. When was the diagnosis made? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. Did you notice any behavioral changes after your child began to have seizures? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. Who currently is providing treatment for your child? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. What kind of treatment is being provided (meds, alternative therapies)? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 6. Is your child still having seizures? If so, how often? How long do they last? How frequently to they occur? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ B. For each instance that your child was hospitalized or placed in out of home care for a medical condition, answer the following questions. Why did your child require such services (surgery, rehab, etc.)? Where was your child placed? How long did your child remain outside the home? What kind of services did your child receive? Did you notice any significant behavioral changes as a result of the placement? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 39 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ CHILD PROTECTIVE SERVICES (For 24-hour urgent response for children removed by Child Protective Services) The questions contained in this addendum are primarily intended to be responded to by the Child Protective Service specialist involved with the child’s case. In addition to this addendum, the assessor should complete the Behavioral Health Client Sheet, the Client Demographic Information Sheet and the following sections in the Core Assessment: Risk Assessment, Observations and Reported Observations of the Child (and if possible, Observations of the Family-Child Interaction), Diagnostic Summary and the Next Steps/Interim Service Plan. The remainder of the Core Assessment should only be completed at this time if the child’s clinical condition/circumstances allow. The assessor should make sure that the Child Protective Service Specialist’s name and phone number is recorded on the Cover Sheet. 1. What are the reasons for the removal of the child from the parent /guardian? Are there other siblings in the family and/or living in the same home? Are other siblings victims of abuse and has CPS removed them? Explain. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. Has the child had prior involvement with Child Protective Services? No Yes, if yes explain. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 3. What is the child’s perception of his/her parents, siblings, and/or family? What is the child’s perception of his/her relationship with his/her parents/siblings/family? What are the child’s feelings, sense of attachment, trust, security, love and affection toward his/her parents/guardian? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. Was the child or the family receiving behavioral health services prior to the removal from the parent/guardian’s home? No Yes, if yes explain. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 40 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ CHILD PROTECTIVE SERVICES (con’t) (For 24-hour urgent response for children removed by Child Protective Services) For Questions 5 through 9 the assessor should check below those statements which best describe the child based on the assessor’s observations and discussion with the Child Protective Service specialist at the time of the interview. 5. General presentation for children 0-3 years of age: 6. 8. Disengaged Head-banging Calm Easy to soothe General presentation for children 4 years of age or older: 7. Crying Clingy Hard to soothe Regressed Tantruming Listless, withdrawn Disinterested Anxious Fearful Angry Labile Fussy Shocked Sad Hearing voices Understanding of removal process: Confused Self Blaming Realistic Distorted Age appropriate No understanding No age appropriate understanding Violent, homicidal Suicidal Relaxed Euthymic Attentive 9. Understanding of placement options: Good Poor No age appropriate understanding Sense of future Hopeful Realistic Unrealistically Optimistic Pessimistic Empowered Planning own destiny Unable to perceive a future No age appropriate understanding 10. Describe the child’s way of coping with the removal (e.g., blaming others, in denial, developing physical symptoms, regressing in behavior, accepting). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 11. What do you or the child feel will be helpful in soothing the child, providing immediate comfort or mitigating the trauma of the removal (e.g., special foods, transitional object, parental visits, maintenance in current school, contact with friends, church attendance.)? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 41 PART B: ADDENDA: BIRTH – 5 Name:_____________________________________ CHILD PROTECTIVE SERVICES (con’t) 12. Describe any requirements of the child welfare plan that may affect the child’s behavioral health service plan (e.g., limited parental or sibling involvement.). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 13. Assessor should provide summary of observations: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 42 PART C: BEHAVIORAL HEALTH SERVICE PLAN: BIRTH – 5 Name: ___________________________________ CIS Client ID# ____________ Program:________________________________ Today’s Date: _____________ Individuals at Service Planning Meeting: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ RECOVERY GOAL/CHILD-FAMILY VISION: CHILD’S STRENGTHS: Review Date (Objective Target Date): ________________ IDENTIFIED NEEDS and SPECIFIC OBJECTIVES (to address these needs) Current Measure INTERVENTIONS to MEET OBJECTIVES Specific Services and Frequency Strengths Used Desired Measure Achieved Measure (at target date) Measure Met (Y/N) 1 2 3 DISCHARGE PLAN (add discharge date if known): Parent/Caregiver ____________________________________________________ Date:____________ Yes, I am in agreement with the types and levels of services included in my service plan. No, I disagree with the types and/or levels of some or all of the services included in my service plan. By checking this box, I will receive the services that I have agreed to receive and may appeal the treatment team’s decision to not include all the types and/ or levels of services that I have requested. * Clinical Liaison___________________________________________ Date:_________ Other______________________________________________ Date:___________ BH Prof. Rev.____________________________________________ Date:_________ Other______________________________________________ Date:___________ ADHS/DBHS: 01/01/06 Version 1.0 43 BEHAVIORAL HEALTH SERVICE PLAN REVIEW OF PROGRESS: BIRTH - 5 Name:_________________________ I. Review of Progress Provide a summary below of the progress the child and family has made toward meeting the objectives identified on the service plan. In addition, indicate any adjustments that are being made to the service plan objectives and/or measures, including the justification and any additional needs or strengths that have been identified. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ II. Current Diagnostic Summary Describe and explain any changes in diagnoses and functioning of the child: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ III. Team Members Present at Plan Review Meeting (CFT Planning): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ IV. Date of Next Plan Review (CFT Planning) Meeting:_____________ V. Clinical Liaison (responsible for reviewing clinical record) _____________________________________________________ Clinical Liaison’s Name (print) / Signature _________________ Credentials/Position ______________ Date _____________________________________________________ Behavioral Health Professional Reviewer Name (print) / Signature _________________ Credentials/Position ______________ Date ADHS/DBHS: 01/01/06 Version 1.0 44 PART D: ANNUAL BEHAVIORAL HEALTH UPDATE AND REVIEW SUMMARY: BIRTH – 5 Name _____________________________________ Date of Birth ____________ Client CIS ID# ___________ Accompanying Family Member/Significant Other (Note relationship to person):__________________________________ Date of Current Assessment/Review ____________ Date of Initial Assessment/Last Review____________ I. STATUS REVIEW 1. Emotional: List all therapeutic interventions/services/supports utilized over the past year (if medications are being used, include in question 2). What helped? What did not help or made the condition worse? What has been the overall functioning over time since the last assessment? What is the current status? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. Medical: describe all medications tried and symptomatic response to treatment; significant medication side effects/adverse drug reactions, AIMS tests; significant changes in medical condition and hospitalizations; physical development ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ List all currently prescribed medications and dosages, including medications prescribed for other physical/medical conditions: Medication __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ Dosage/Frequency ____________________ ____________________ ____________________ ____________________ ____________________ Purpose ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ 3. Environmental: List all significant events/trauma since the last assessment/review, placements outside the home; family’s cultural preferences/ considerations for service provision. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 4. Progress: Describe child’s progress in reaching treatment objectives (Consider functioning related to the following areas as appropriate: living environment; activities of daily living; school preparation; interpersonal relationships; developmental progress). ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. Risk Factors: Describe any significant long-term chronic risk factors such as harm to self or others; exposure to drug use; personal drug use; nutrition; exploitation, abuse, or neglect. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ADHS/DBHS: 01/01/06 Version 1.0 45 PART D: ANNUAL BEHAVIORAL HEALTH UPDATE AND REVIEW SUMMARY: BIRTH – 5 II. CURRENT DIAGNOSIS 1. Axis I. DSM-IV TR Code _______________ _______________ _______________ _______________ _______________ 2. Diagnosis ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ Justification for diagnoses (es) _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ Axis II . DSM-IV TR Code Diagnosis Justification for diagnosis (es) _______________ ___________________________ _______________________________________________________ _______________ ___________________________ _______________________________________________________ 3. Axis III. Identify the child’s specific medical conditions and check below the disease categories that apply. Infectious and Parasitic Diseases (001-139) Neoplasms (140-239) Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders (240-279) Diseases of the Blood and Blood-Forming Organs (280-289) Diseases of the Nervous System and Sense Organs (320-389) Diseases of the Circulatory System (390-459) Diseases of the Respiratory System (460-519) Diseases of the Digestive System (520-579) Diseases of the Genitourinary System (580-629) Complications of Pregnancy, Childbirth, Puerperium (630-676) Diseases of the Skin and Subcutaneous Tissue (680-709) Diseases of the Musculoskeletal System and Connective Tissue (710-739) Congenital Anomalies (740-759) Certain Conditions Originating in Perinatal Period (760-779) Symptoms, Signs, and Ill-Defined Conditions (780-799) Injury and Poisoning (800-999) 4. Axis IV. (Psychosocial or Environmental Stressors) _______________________________________________________________ 5. Axis V. (CGAS score)____________ ADHS/DBHS: 01/01/06 Version 1.0 46 PART D: ANNUAL BEHAVIORAL HEALTH UPDATE AND REVIEW SUMMARY: BIRTH – 5 III. RECOMMENDATIONS FOR CURRENT AND ONGOING SERVICE/TREATMENT 1. List prior goals that have not been achieved that still need to remain a focus of services/treatment: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 2. List any new goals for the service plan: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 3. List other ongoing needs or concerns that need to be addressed, including coordination of care with PCP: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 4. Identify any areas in the assessment that need to be reassessed due to significant changes, e.g., child’s condition, living environment, support structure: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ -----------------------------------------------------------------------------------------------------------------------------------------------------------_________________________________________________________ Clinical Liaison’s Name (print) / Signature ____________________ ____________ Credentials/Position Date __________________________________________________________ Behavioral Health Professional Reviewer Name (print) / Signature ____________________ ____________ Credentials/Position Date ______________________________________________________ Agency REMINDER: All demographic data reported to ADHS/DBHS must be reviewed during annual update. Based on this review: At a minimum the following demographic/clinical data fields must be reported to ADHS/DBHS regardless of whether they have changed since the last data submittal: Axis I, II and V, behavioral health category, educational status, primary residence, since the last data update and primary and secondary substance use; and/or All other demographic information that has changed (e.g., other agency involvement, income for non-Title XIX/XXI eligibles). ADHS/DBHS: 01/01/06 Version 1.0 47
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